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Wasted COVID-19 vaccine is rare in Virginia. But experts say it’s getting harder to avoid.

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A basket of syringes containing the Moderna COVID-19 vaccine ready to be used at Richmond Raceway in Richmond, Feb. 2.

Courtesy of the Virginia Mercury

Virginia providers have wasted fewer than 4,000 doses of COVID-19 vaccine out of the nearly 6 million administered through late April, according to data provided to the Mercury by the state Department of Health.

The figures only include wastage from settings supplied through the state’s vaccine allocation, which is managed separately from federal programs that routed about 310,000 additional doses to pharmacy partners and other clinics over the same time period.

But for vaccinators, the tiny fraction of state wastage — roughly 0.06 percent of all doses administered — is a testament to the careful logistics that go into planning large-scale clinics. It’s especially impressive, they say, given the delicacy of the two mRNA vaccines — Pfizer and Moderna — that make up most of Virginia’s supply.

As the state overhauls its vaccination strategy, though, experts say wastage is almost guaranteed to go up. That certainty will require providers to make new choices when it comes to managing supply, and an overhaul of how the public views the concept of unused doses.

“I think we’re at a point where, since we have supply exceeding demand, we have to understand there will be more wasted vaccines,” said Dr. Costi Sifri, the director of hospital epidemiology at UVA Health. “And that’s because we’re doing things differently now.”

Wastage has been the subject of scrutiny — by the Mercury and multiple national outlets — since the first doses were shipped out in mid-December. With limited supply and high demand, any unused doses were rightly viewed, by both providers and the public, as wasted opportunities to immunize someone against a potentially deadly virus.

But the logistical challenges of available vaccines made wastage difficult to avoid completely. For the first two months of Virginia’s rollout, Pfizer and Moderna were the only vaccines authorized for use by the U.S. Food and Drug Administration. The one-dose Johnson & Johnson vaccine was authorized in late February, but multiple hurdles — including a manufacturing error that led to 15 million discarded doses and a temporary pause to investigate reports of extremely rare blood clotting — have reduced the state’s supply.

Both Pfizer and Moderna use new messenger RNA technology that delivers genetic material to human cells — teaching immune systems to protect themselves against the COVID-19 virus. Neither vaccine contains preservatives, and mRNA is fragile. As a result, both vaccines need to be stored in exceedingly cold environments to keep them stable.

Additionally, all three vaccines come in multi-dose vials that expire hours after they’re punctured. The Johnson & Johnson vaccine, for example, uses different technology that makes it the most stable of the bunch. Unlike Pfizer and Moderna, it can be stored at normal refrigerator temperatures until its use-by date. Still, punctured vials only last for two hours at room temperature, and six when they’re held in the fridge.

“It’s all pretty fragile stuff,” said Dr. Richard Williams, director of the Three Rivers Health District on the Middle Peninsula. Some of the biggest single instances of waste were the result of technology failures or improper storage. In March, Sentara Norfolk General Hospital recorded 140 wasted Moderna doses — the second-largest single report in the state — after what Jon Horton, the system’s pharmacy director, described as a one-time error.

“We had some vials that were in a mobile freezer and we had contacted our courier about picking them up for transportation to another site,” he said. (Most shipments to Sentara are delivered to Norfolk General and redistributed to other hospitals within the system). Later that evening, Horton said his staff alerted him that the vials hadn’t been collected.

He asked them to move the doses to the main freezer, but discovered the next day that the Moderna vials had been placed in ultracold storage where the system keeps its Pfizer vaccine. The health system mostly uses Pfizer, and Horton said it was an honest mistake. But since Moderna’s storage requirements call for slightly higher temperatures when frozen, the vials had to be discarded.

A few weeks later a power surge knocked out the backup generator at the Middlesex Health Department. The surge also disabled the storage fridge where the department was keeping 1,300 doses of Moderna. The temperature only went three degrees above the maximum allowable storage range, he said. But Moderna told the department it would have to use up all 1,300 doses within the next 12 hours.

“It was a mad scramble that day to try to get this vaccine to places where people could use it,” Williams said. Local officials pushed it to clinics across the district, including vaccination events organized by Riverside and Bon Secours. But by the end of the day, the department was still forced to throw away 600 doses. The only blessing, Williams said, was that it happened when it did. The district saw an increase in vaccine shipments the very next week.

“We were at a phase where we could absorb the loss not only at the district level, but at the state level, and not have to cancel or delay any appointments,” he said. “Still, it was extremely disappointing.”

Those larger-scale events, resulting in dozens or hundreds of discarded doses, have occasionally caused state wastage data to spike. But over time, the amount of waste has crept up incrementally for other reasons. Despite occasional rumors of whole vials being discarded at large vaccination sites, sizeable instances of waste — with more than 10 lost doses — happened rarely (and only once at a community vaccination clinic in Danville where two Moderna vials were broken).

Instead, shots are lost for more banal reasons. The most common explanation has been vials that are opened without using up every available dose. Sometimes, vaccines are drawn into a syringe but never used. Often, it’s only a dose or two per clinic that adds up over time.

Health officials do their best to avoid that kind of waste. The pre-registration system that existed for most of the state’s rollout was designed to help hospitals and health districts plan how much vaccine they needed to thaw for every event. Horton said Sentara typically unfroze around 70 percent of the doses it expected to use, thawing more vials onsite as needed.

And for most of the state’s rollout, when demand was consistently high, wastage rarely happened. Until recently, both local health departments and hospitals delivered vaccines through large events that accommodated hundreds or thousands of patients a day. “A month ago, if we offered an event with 2,000 doses, we got 2,000 patients,” Horton said.

But over the last month, health departments have witnessed demand for those clinics drop precipitously. Even Richmond, where it’s declined more gradually, didn’t see a surge in new registrations or appointments after the local health district expanded vaccine eligibility to everyone 16 and older in early April.

District spokeswoman Cat Long said supply has also increased significantly over the last several weeks. Appointments through local pharmacies — once difficult to find and restricted to certain groups — are now readily available for most Virginians.

“There are just more opportunities to get vaccinated,” she said. “That’s the good news, though it does make it more challenging to understand the data.”

As demand slows throughout most of the state, local health departments and VDH are changing their vaccination strategies. Richmond recently closed a mass vaccination site at the Arthur Ashe Center in favor of smaller “community hub” events, some targeted at census tracts with lower vaccination rates than other parts of the city. The district is also launching walk-up clinics for the general public.

Walk-ins are now gaining traction throughout most of the state. Just a week after opening a new mass vaccination site at Tysons Corner, Fairfax County announced the shots would be available on a first-come, first served basis. On Friday, state vaccine coordinator Dr. Danny Avula said the state was shifting its focus to primary care doctors and other community health workers who could offer more targeted outreach.

For most providers, it’s a significant change in strategy, and one that makes avoiding waste much more challenging. Long said the Richmond-Henrico Health District has always tried to schedule appointments in groups of five or 10 to ensure doses in a vial don’t go to waste. But with walk-ins — and a growing number of no-shows — gauging interest isn’t easy to predict.

“It certainly makes it more challenging to know how many vaccines we should bring out and how many we should draw when we don’t have any estimate of how many people will come out,” she said. And as vaccinations become more individualized, it shifts decision-making. If two people show up at a pharmacy right before closing and there are no open vials, should the pharmacist puncture a new one? Should hospitals start offering doses to unvaccinated inpatients?

“That’s one of the things we struggle with now,” Horton said. “Today, I think there are four patients at Norfolk General who need a second dose of Moderna. But I would have to have 10 patients in order not to waste any doses.”

As the calculus shifts, some providers say there needs to be more tolerance, among professionals and the public, toward the idea of vaccine wastage. UVA Health is moving forward with plans to offer Johnson & Johnson vaccines to patients before they’re discharged from the emergency room — a pilot that was momentarily paused while the vaccine was being investigated. Sifri said he’s still waiting to learn more about the demand, but would be reluctant to only use one or two doses out of a five-dose vial.

For smaller providers, it might become at least an occasional necessity. Avula said VDH is in the process of directing smaller shipments to primary care providers and pharmacies who can’t always use up the minimum order size offered by manufacturers (both Moderna and Johnson & Johnson are available in 100-dose increments, but Pfizer’s shipping trays contain 1,170 shots apiece). But even in more manageable quantities, it’s better to waste a dose than potentially leave someone unvaccinated, said Stacey Swartz, co-owner of The Neighborhood Pharmacy in Alexandria.

“It’s a lovely problem to have, that you can’t find 10 people who need a vaccine,” she said. “But at the same time, we know those people are out there, and you’ve got to make sure you’re getting it to those people.”

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